Clinical utility of transperineal template-guided mapping biopsy of the prostate after negative magnetic resonance imaging-guided transrectal biopsy

PURPOSE

We evaluated the prostate cancer detection with transperineal template-guided mapping biopsy in patients with elevated prostate-specific antigen and negative magnetic resonance imaging (MRI)-guided biopsy.

MATERIALS AND METHODS

Totally 75 patients underwent transperineal template-guided mapping biopsy for prior negative MRI-guided (cognitive registration) biopsy during April 2013 to August 2014. Primary objective was to report clinically significant cancer detection in this cohort of patients. Significant cancer was defined using varying thresholds of MCL or Gleason grade 3+4 or greater or both. Cancers with more than 80% of positive core length anterior to the level of urethra were termed anterior zone cancer. Secondary objective was to evaluate the potential clinical and radiological predictors for significant cancer detection.

RESULTS

The mean age was 61.6 ± 6.5 years and median prostate-specific antigen was 10.4 ng/dl (7.9-18) with a mean MRI target size of 7.2mm (4-11). Transperineal template-guided mapping biopsy identified cancer in 36% (27/75) patients and 66.6% (18/27) of them were anterior zone cancers. The rates of detection of clinically significant and insignificant cancer according to the several definitions used range from 22.7% to 30.7% and 5.3% to 13.3%, respectively. Multivariate analysis did not identify any predictors for finding clinically significant and anterior cancers in this group of patients.

CONCLUSION

Transperineal template-guided mapping biopsy appears to be an excellent biopsy protocol for downstream management following negative MRI-guided biopsy. Most of the cancers detected were predominantly anterior tumors.

Surgical margins and biochemical recurrence risk at 2 years for robotic prostatectomy: Comprehensive evaluation and CUSUM analysis of oncological outcomes

80

Background: To evaluate the learning curve of Minimally Invasive Radical Prostatectomy (MIRP) in our institution and apply the cumulative summation (CUSUM) analytical technique to identify salient learning curve transition points in terms of oncological outcomes. Methods: Clinical, pathologic, and oncological outcome data were collected from our prospectively collected MIRP database to estimate Positive Surgical margin (PSM) and Biochemical Recurrence (BCR) trends during a 15 year period from 1998 to 2013. All the RPs (laparoscopic (LRP) / Robotic Assisted [RARP]) were performed by 9 surgeons. PSM was defined as presence of cancer cells at inked margins. BCR was defined as serum Prostate Specific Antigen (PSA) >0.2 ng/ml and rising or start of secondary therapy. Surgical learning curve was assessed with the application of Kaplan-Meier curves, Cox regression model, CUSUM and logistic model in order to define the “transition point” of surgical improvement. Results: We identified 5,547 patients with localized prostate cancer treated with MIRP (3,846 - LRP and 1,701 – RARP). Patient characteristics of LRP and RARP were similar. The overall risk of PSM in LRP was 25%, 20% and 17% for the first 50, 50 to 350 and >350 cases, respectively. For the same population, the 5-year BCR rate decreased from 21.5% to 16.7%. RARP started 3 years after the LRP program (after approximately 250 LRP). The PSM rate for RARP decreased from 21.8% to 20.4% and the corresponding 5-year BCR rate decreased from 17.6% to 7.9%. The CUSUM analysis showed significantly lower PSM and BCR at 2 years occurred at the transition point of 350 cases for LRP and 100 cases for RARP. In multivariable analysis, predictors of BCR were PSA, Gleason score, extra prostatic disease, seminal vesicle invasion and number of operations (p < 0.05). Patients harboring PSM showed higher BCR risk (23% vs. 8%, p < 0.05). Conclusions: Learning curve trends of MIRP in our large, single center experience showed significant reduction in PSM and BCR risk at 2 years are noted after the initial 350 cases and 100 cases of LRP and RARP, respectively.

Comprehensive evaluation of the clinical utility of transperineal template guided mapping biopsy of prostate in the era of magnetic resonance imaging

55

Background: To evaluate the clinical utility of Transperineal Template guided Mapping Biopsy (TTMB) after the routine use of Magnetic Resonance Imaging (MRI) for prostate cancer in our institution. Methods: We retrospectively analyzed 208 TTMB performed at our institution from April 2013 - August 2014. Anterior cancer defined as ≥ 80% of the positive cores anterior to urethra. Clinically significant cancer detection verified at various thresholds of Maximum Cancer Core Length (MCL) – 2mm / 3mm / 4mm / 6mm ± Gleason score (GS) ≥ 3+4. We analyzed TTMB for the indications, cancer detection and correlation with TRUS, MRI and Radical Prostatectomy (RP) specimens. Results: The indications and cancer detection rates of TTMB are in the table. All the patients had MRI before TTMB and 87.7% had it prior to the initial TRUS and all target biopsies were by cognitive registration. Multivariate analysis showed higher number of TTMB cores and prior negative TRUS to predict detection of clinically significant anterior tumor. The laterality of cancer in TTMB correlated with TRUS, MRI and Radical Prostatectomy (RP) in 67.2%, 75.3% and 87.6% respectively. The Gleason upgrade from TRUS to TTMB was 19.2% and TTMB to RP was 14.8%.Clavien-Dindo grade 1 and 2 complication was noted in 40.2% and 7% patients respectively. Conclusions: Even with the routine of MRI prior to TRUS biopsy, TTMB had clinical utility and was very effective in detecting clinically significant cancers in specific clinical situations. [Table: see text]

Charlson score to predict overall survival and cancer-related death in elderly patients featuring high-risk prostate cancer

84

Background: In elderly patients, Charlson score among other features, might allow clinicians to limit the use of aggressive adjuvant treatment strategies or even primary surgical treatment to those who might not achieve benefit during their lifetime. Methods: Retrospective analysis, 7,650 case multicenter high-risk prostate cancer (Pca) radical prostatectomy database selecting >= 70 years old cases. We predicted death from all causes (DAC) and cancer related death (CRD) including all clinical and pathological data. Multivariable analysis were performed to identify independent predictors of DAC and CRD with binary logistic regression, using STATA® software, version 13.1. Results: 2,106 patients from 14 high-volume centers were included. Mean age was 72.8 years (SD 2.46). 206 (9.78%) patients were classified as ASA 3-4 and 497 (23.6%) as CS >=1. Mean PSA was 21.7 ng/ml (SD 50.5). At final histopathology, 800 (38%) had pT3b-T4 disease, GS was 8-10 in 589 (28%), LNI was found in 518 (24.6%) and 822 (39%) PSM. Adjuvant RT, ADT and RT+ADT were administered in 359 (17%), 391 (18.6%) and 437 (20.7%), respectively. Mean follow up was 5.18 years (DS 4.47). BCR occur in 649 (30.8%) and CF in 150 (7.1%) of which distant in 59 (2.8%). Total deaths accounted 341 (16.2%) and CRD for 100 (4.7%) cases. Conclusions: Multicenter data confirms that elderly patients survival harboring high risk prostate cancer will benefit from radical treatment if they are Charlson score 1 or less. [Table: see text] [Table: see text]

Predictors of pathological upgrading and upstaging in patients eligible for active surveillance submitted to radical prostatectomy (RARP)

59

Background: To evaluate the pathological outcomes in patients who were suitable for Active Surveilance (AS) and underwent Radical Prostatectomy (RP) and to explore the potential predictive factors to identify Gleason upgrading and upstaging. Methods: A prospectively maintained database was used to evaluate 1,552 consecutive patients who underwent RP [Laparoscopic / Robotic] at our institution between 1998 and 2012. We identified 405 RP patients fulfilling the Memorial Sloan-Kettering Cancer Center criteria for AS (PSA ≤10 ng/ml, clinical stage ≤2a, Gleason≤6, ≤2 + cores and less 50% cancer in any one core). In the final RP specimen, upgrading was defined as identification of Gleason >6 and upstaging as presence of ≥ pT3. The clinical and the pathological features of upstaged/upgraded patients were compared with the remaining patients and the cox’s regression model was applied to identify potential predictors. Kaplan Meir curve was used to identify Biochemical Recurrence Free Survival (BCR-FS) at 5 years. Results: We noticed upstaging in 195 (48%) patients and Gleason upgrading in 55 (13%) at RP specimen. Multivariate analysis showed percent of positive core had significant association with upstaging/upgrading. Positive Surgical Margin (PSM) was noted in 66(16%) patients, and the PSM rate was significantly higher in upstaged patients. The mean follow-up of the study population was 28 months and the predicted BCR-FS at 5 years was 92% and 88% in the patients who were not and were upstaged/upgraded. Conclusions: Percentage of positive cores in patients subjected to Active Surveillance appears to predict pathological upstaging/upgrading at radical prostatectomy. [Table: see text]

Transperineal template-guided mapping biopsy of the prostate

Accurate diagnosis of prostate cancer has eluded clinicians for decades. With our current understanding of prostate cancer, urologists should devise and confidently present the available treatment options – active surveillance/radical treatment/focal therapy to these patients. The diagnostic modalities used for prostate cancer have the dual problem of false negativity and overdiagnosis. Various modifications in the prostate biopsy techniques have increased the accuracy of cancer detection, but we are still far from an ideal diagnostic technique. Transperineal template-guided mapping biopsy of the prostate is an exhaustive biopsy technique that has been improvised over the past decade, and has shown superior results to other available modalities. We have carried out a PubMed search on the available experiences on this diagnostic modality, and along with our own experiences, we present a brief review on transperineal template-guided mapping biopsy of the prostate.

Primary prostatic lymphoma in a young male with hiv infection

Primary lymphoma involving the prostate gland is rare. It accounts for 0.09 % of prostatic malignancies [1]. It commonly presents in the seventh decade with Lower Urinary Tract Symptoms (LUTS). Diffuse large B cell lymphoma is the common pathological variant [2]. Chemotherapy and radiotherapy are the common modalities of treatment and the overall prognosis is poor [2]. We present a 26 year old HIV infected patient - on anti-retroviral therapy who presented with acute renal failure and grossly enlarged prostate. Prostate biopsy with immuno-histochemistry confirmed the diagnosis of Peripheral T-cell lymphoma. He was treated with Adriamycin based chemotherapy and radiotherapy. We report this case in view of the rarity the tumor, younger age at presentation than that is available in literature and the pathological variant not reported in primary prostatic lymphoma.

[Bidirectional barbed suture for bladder neck reconstruction, posterior reconstruction and vesicourethral anastomosis during robot assisted radical prostatectomy]

BACKGROUND

The urethrovesical anastomosis is a particular challenging step of robot assisted radical prostatectomy (RARP). Failure to achieve a watertight anastomosis is associated with postoperative urinary leak and its consequences, which include paralytic ileus, prolonged catheterization, urinary peritonitis and possibly re-intervention. The bidirectional barbed suture is a new technology that may lead to improve the quality of the urethrovesical anastomosis.

OBJECTIVE

To present our surgical technique of urethrovesical anastomosis, bladder neck reconstruction and posterior reconstruction, using a bidirectional barbed suture.

MATERIAL AND METHODS

The bladder neck reconstruction, posterior reconstruction and vesicourethral anastomosis were performed using a 2-0 synthetic absorbable bidirectional monofilament barbed suture

RESULTS

All cases were finished successfully without major complication or conversion to laparoscopic or open surgery.

CONCLUSION

The authors successfully modified their RARP technique to take advantage of the properties of the bidirectional barbed suture. Comparative studies that evaluate objective outcomes such as leakage rates and operative time are needed to definitely establish the benefits of this device in comparison to the traditional absorbable monofilament.

Cecal volvulus associated with intestinal malrotation presenting as postoperative intestinal obstruction

OBJECTIVE

To report a case of intestinal malrotation predisposing to cecal volvulus following nonabdominal surgery in an adult.

PRESENTATION AND INTERVENTION

A 23-year-old male with known anorectal malformation developed a postoperative intestinal obstruction following percutaneous nephrolithotomy for left renal calculus. Computed tomography of the abdomen revealed a grossly dilated cecum (9 cm) with ileocecal junction on the left side and small bowel loops on the right side of the abdomen. The patient underwent emergency exploratory laparotomy and retroperitonealization cecopexy. Bowel functions were normal at the follow-ups.

CONCLUSION

This case highlights the importance of suspecting cecal volvulus even following nonabdominal surgery in the presence of predisposing factors.

Nail patella syndrome: a rare cause of renal failure in a young adult

Nail Patella Syndrome (NPS) is a rare hereditary disease affecting multiple systems with predominant involvement of Kidney, Bones and Nails and Eyes. We report a case of NPS which presented as renal failure in a 22 year old male. The patient was admitted with decreased urine output and features of fluid overload and was being evaluated for renal failure. Physical examination revealed associated bony deformities which raised the suspicion of NPS as a possible etiology. This was confirmed by the radiological evaluation which showed the classical features of NPS. Though NPS is a rare clinical condition, physicians should complete knowledge about the components of NPS for appropriate diagnosis and for early detection of other systems involvement.

[Robotic surgery: history and teaching impact]

CONTEXT

The purpose of this article is to review the history of robotic surgery, its impact on teaching as well as a description of historical and current robots used in the medical arena.

SUMMARY OF EVIDENCE

Although the history of robots dates back to 2000 years or more, the last two decades have seen an outstanding revolution in medicine, due to all the changes that robotic surgery has made in the way of performing, teaching and practicing surgery.

CONCLUSIONS

Robotic surgery has evolved into a complete and self-contained field, with enormous potential for future development. The results to date have shown that this technology is capable of providing good outcomes and quality care for patients.

Predictors of malignancy in pancreatic head mass: a prospective study

Introduction

The objective of the study was to identify the predictive factors for malignancy in pancreatic head mass as a primary outcome and assess the value of CA 19-9 as a diagnostic tool for malignancy as a secondary outcome.

Methods

A prospective study of patients presented with pancreatic head mass was conducted in a tertiary care referral hospital, Manipal, India from May 2006 to November 2008. The study population was divided into malignant and benign groups based on the final histopathology report. A univariate and multivariate analysis of potential predictive factors for malignancy were conducted.

Results

A total of 102 patients with pancreatic head mass were included in the study after fulfilling the inclusion/exclusion criteria. 78 were malignant and 24 were benign. There was significant weight loss (p<0.001) and high mean bilirubin levels (p=0.002) in the malignant group. Mean CA 19-9 was significantly higher in the malignant group (290.7 vs. 30.3 U/ml; p<0.001). Sensitivity and specificity of CA 19-9 for detecting malignancy in pancreatic head mass at a cut off of 35U/ml was 86% and 79% respectively. CA 19-9 positivity rate was higher with increasing cut off values of 100, 200 and 300U/ml but such high levels occurred in fewer patients. All the non-jaundiced patients (100%) with raised CA 19-9 levels were found to be malignant compared to 86% malignancy in jaundiced patients. In multivariate analysis, a combination of weight loss>10% of body weight and bilirubin>3 mg/dl and CA 19-9>35U/ml had specificity and positive predictive value of 100% for predicting malignancy in pancreatic head mass.

Conclusion

The presence of weight loss and jaundice and raised CA 19-9 levels together in a patient with pancreatic head mass can be predictive of malignancy. A very high CA 19-9 level can be an indicator of malignancy in a pancreatic head mass. A raised CA 19-9 level may be more predictive of malignancy in non-jaundiced patients than in jaundiced patients.

Repair of spondylolysis using compression with a modular link and screws

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation. The strength of the construct removes the need for post-operative immobilisation.

A microscale in vitro physiological model of the liver: predictive screens for drug metabolism and enzyme induction

In vitro models of the liver using isolated primary hepatocytes have been used as screens for measuring the metabolism, toxicity and efficacy of xenobiotics, for studying hepatocyte proliferation, and as bioartificial liver support systems. Yet, primary isolated hepatocytes rapidly lose liver specific functions when maintained under standard in vitro cell culture conditions. Many modifications to conventional culture methods have been developed to foster retention of hepatocyte function. Still, not all of the important functions -- especially the biotransformation functions of the liver -- can as yet be replicated at desired levels, prompting continued development of new culture systems. In the first part of this article, we review primary hepatocyte in vitro systems used in metabolism and enzyme induction studies. We then describe a scalable microreactor system that fosters development of 3D-perfused micro-tissue units and show that primary rat cells cultured in this system are substantially closer to native liver compared to cells cultured by other in vitro methods, as assessed by a broad spectrum of gene expression, protein expression and biochemical activity metrics. These results provide a foundation for extension of this culture model to other applications in drug discovery -- as a model to study drug-drug interactions, as a model for the assessment of acute and chronic liver toxicity arising from exposure to drugs or environmental agents; and as a disease model for the study of viral hepatitis infection and cancer metastasis.

Cellular Destruction Following Transmyocardial Laser Revascularization (TMR)

During transmyocardial revascularization, cellular destruction of cardiomyocytes occurs as a result of the high-energy laser. However, the features of myocardial cellular destruction are unclear. The present study was undertaken to examine the structural characteristics of cell death in the myocardium following transmyocardial revascularization. Myocardial specimens from 3 male patients who had died within 11 days following laser revascularization were collected within 1 h of death and were analyzed by immunohistochemistry and electron microscopy. For immunohistochemistry, antibodies to pro-apoptotic proteins CPP32 and BAX were used. Immunohistochemical examination demonstrated the presence of cells expressing both CPP32 and BAX along the laser channel. Electron microscopic analysis revealed that the lining surface of laser channels consisted of condensed acellular debris and dead cells. No endothelialization of channels was noted. The lumen of laser channels were surrounded by a rim of acellular debris with several outer concentric rims of cardiomyocytes showing features of cellular destruction. The present study identified features of both necrotic and apoptotic cellular death following laser revascularization.

Hydatid cyst of the left ventricle of the heart

Hydatid disease of the heart is rare. We report a case of hydatid cyst of left ventricle in a forty year old lady where the diagnosis was made intra-operatively. The transthoracic and transesophageal echocardiography showed a mixed echogenic mass arising from the left ventricle. The diagnosis of hydatid cyst was confirmed by the demonstration of scolex and hooklets in the cyst fluid. Hydatid cyst should be a differential diagnosis for a mixed echogenic mass on echocardiography.

Invasive pulmonary aspergillosis with intraspinal extension in a non-immunocompromised host. A case report

A case of invasive pulmonary aspergillosis in a 33-year-old, non-immunocompromised male presenting with lower limb paraplegia is reported. The clinical manifestations, diagnosis, and combined medical and surgical management of this rare condition are described.

Intravascular ultrasound-guided angioplasty and stenting in a case of transplant coronary artery disease

Allograft vasculopathy in cardiac transplant recipients occurs commonly at 5 years post transplantation. We report a case of post-transplant right coronary discrete stenosis which was treated with balloon angioplasty and stent implantation under intravascular ultrasound guidance.

Sclerosing mediastinitis caused by Aspergillus terreus

A case of Aspergillus terreus causing sclerosing mediastinitis which presented with symptoms of cardiorespiratory compromise and compressive myelopathy is described. The diagnosis was established by culturing and isolating the fungus in pure culture from the tissue and was also confirmed by demonstration of sepcific precipitating antibodies against Aspergillus terreus in patient's serum.

Pathology of the diffuse variant of supravalvar aortic stenosis

Supravalvar aortic stenosis is a rare congenital heart anomaly, producing left ventricular outflow tract obstruction. Of the two anatomic variants that have been described, diffuse type is the rarest. We report five such cases in children between two months and nine years of age. None had features of Williams syndrome. The entire aorta was involved in three cases, with abdominal aortic coarctation in two cases. Stenosis was mainly due to involvement of the media, which showed smooth muscle hypertrophy, abnormal elastic fibers, and mild collagenization. Predominant intimal change was seen in one case. Pulmonary, coronary, arch, renal, and common iliac arteries were also involved.

Cardiac pathology of permanent pacemaker implementation

The cardiac findings in five cases of permanent pacemaker implantation seen at autopsy in a three-year period is reported. Implantation was done for complete heart block in four patients and sick sinus syndrome in one. The periods of implantation ranged from seven days to four years. The common findings were right sided valvar and mural bland thrombus formation. Additional findings included superior vena caval thrombosis, endocardial 'tunnel' formation for the pacing wires, perforation of the tricuspid leaflet and a gross morphology similar to that seen in right sided endomyocardial fibrosis.

Subvalvular left ventricular aneurysms

Subvalvular left ventricular aneurysms can be subaortic or submitral with variable etiology. This is a retrospective study of 19 subvalvular aneurysms seen in 16 cases. There were 12 isolated subaortic aneurysms, 3 isolated submitral aneurysms, and in 1 case with multiple subaortic and submitral aneurysms. Subaortic aneurysms were associated with infective endocarditis, while there seems to be a strong association between submitral aneurysms and tuberculosis. Five cases of subvalvular aneurysm has associated aneurysm sinus of Valsalva-this association suggests a congenital weakness in the attachment of aortic and mitral annuli to the underlying myocardium. Cardio Pathol 2000;9:267-271

Intrapericardial teratoma--a report of two cases

Two rare cases of intra-pericardial teratoma in infants are reported. The presenting symptoms were either due to pericardial effusion and cardiac tamponade or due to compression of the tracheo-bronchial tree. The tumors were well encapsulated and were attached to the ascending aorta. Histologically, they were composed of derivatives of the three germ cell layers.

Isolated right ventricular infarction

Rare occurrence of isolated right ventricular infarction is reported in four patients, three of whom were elderly. The causes of infarction were due to pulmonary thromboembolism and dissection of non-dominant right coronary artery. None of the hearts had right ventricular hypertrophy and significant coronary atherosclerosis.

Carcinoma arising within fibroadenoma--a case report

A rare case of ductal carcinoma-in-situ in multiple fibroadenomas of the breast in a 43 year old female is reported.

Neonatal candidial endocarditis--a rare manifestation of systemic candidiasis

Infective candidial endocarditis in four premature neonates is reported. These occurred as a complication of systemic candidiasis. Vegetations were present on the right side of the heart in two cases and both sides in the other two. Diagnosis requires a high degree of clinical suspicion. Mortality rate is high despite appropriate therapy.

Aortic dissections: a pathologic study of 35 autopsied cases

A study of 35 autopsied cases of aortic dissection collected over a period of 12 years was carried out. There were 25 males and 10 females, and the majority of the dissections presented in fourth to fifth decade of life. Thirty-six dissections were present in 35 cases. Type III was the commonest (50.0%), followed by Type I (41.7%) and Type II (8.3%) dissections. Rupture following acute dissection was the cause of death in 15 patients. In chronic types, the causes of death were not related to dissection. Hypertension, connective tissue disorders and trauma were identified as some of the risk factors.

Pulmonary carcinomatous arteriopathy--a rare cause of dyspnoea and pulmonary hypertension

Pulmonary carcinomatous arteriopathy was seen at autopsy in three patients who presented with sub-acute cor pulmonale. All had adenocarcinomas of unknown origin. The arteries and arterioles showed fresh and organizing thrombi with narrowing or occlusion. Large muscular arteries also showed tumour cells within the thrombi. Lymphangitis carcinomatosis was also present to a variable extent.

Is haemorrhagic myocardial infarction more common with streptokinase?

Autopsy reports and clinical data of 226 consecutive myocardial infarction deaths in whom postmortem studies could be carried out during the period 1980 to 1996 were analyzed retrospectively for the presence of haemorrhagic myocardial infarction (HMI). Of 53 autopsies done from 1980 to 1986 [prior to use of streptokinase (SK) therapy in our institution] none of the specimens showed haemorrhagic infarction. Of 173 autopsies done from 1987 to 1996 (intravenous SK therapy was utilised in this period), 20 specimens showed haemorrhagic infarctions. Sixteen of these 20 patients had received SK, while 66 of the remaining 153 non-haemorrhagic myocardial infarction patients received SK (statistically significant association of SK with HMI, p < 0.005). Acute mechanical complications [ventricular septal rupture (n = 10), papillary muscle rupture (n = 2), cardiac free wall rupture (n = 7)] were seen in 19 cases. Of these, 16 were HMIs and 14 of these patients had received streptokinase. These observations suggest a strong association of HMI with SK therapy and with acute mechanical complications.

Pneumocystis carinii pneumonia in human immunodeficiency virus infected patients in Bombay: diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy

We report Pneumocystis carinii pneumonia (PCP) diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy in three out of five human immunodeficiency virus (HIV) positive adult patients presenting with interstitial pneumonitis. One of these patients was serologically positive for HIV at the time of presentation and the remaining two patients were detected to be HIV positive on follow up after the diagnosis had been established. All the three patients were treated with co-trimoxazole. One patient recovered and was discharged; another patient improved with treatment but died after jugular vein cannulation and the third patient succumbed to cryptosporidial diarrhoea. The remaining two patients with non-specific interstitial pneumonitis treated with prednisolone and bronchodilators were recovered and were discharged from the hospital.

Right-ventricular fibroma presenting as tricuspid stenosis--a case report

A male child presented with suspicion of tricuspid stenosis. Echocardiography revealed the presence of a mass arising from the free wall of the right ventricle and causing right-ventricular inflow obstruction but not involving the tricuspid valve. The tumour was excised via right ventriculotomy using cardiopulmonary bypass, resulting in survival and a satisfactory clinical course. Histological examination showed the tumour to be a fibroma. Tricuspid stenosis is an unusual presentation of right ventricular fibroma. Careful examination is essential to early diagnosis of cardiac fibromas, particularly in children with unexplained cardiac problems. Echocardiography is still a good method for confirmation of the diagnosis and for follow-up. In view of the unknown natural history of cardiac fibroma, surgical excision should be undertaken. Early detection and prompt excision results in immediate and complete relief of symptoms and prolongs the life span.

Coronary artery-intramyocardial sinusoid communication in a case of pulmonary atresia with intact ventricular septum

Intramyocardial sinusoid--coronary artery fistulous communications are well established channels in pulmonary atresia with intact ventricular septum. Angiographically flow can be demonstrated from the right ventricular cavity into the coronary arteries. We have histologically demonstrated such a communication in a case of pulmonary atresia with intact septum.

Balloon mitral valvotomy: an autopsy study

The autopsy findings in 20 patients who died following percutaneous balloon mitral valvotomy are reported. The procedure was attempted in 508 patients. In 17 of the 20 patients, balloon mitral valvotomy was attempted as a salvage procedure. Ten patients died in the immediate post valvotomy period (within 24 h), seven died within a week and three between 1 to 3 months. In 13 patients, the balloon valvotomy successfully opened out one or both commissures. Interatrial septostomy defects created by the transeptal catheter could be identified in 19 of 20 heart specimens. The size of the defects ranged from small (5 mm) openings to large (15 mm) defects especially with double balloon. Marked mitral valvar thickening with nodular calcification was observed in 16 cases. Significant complications leading to mortality included cardiac tamponade (five cases) due to left ventricle apical perforation (3/5 cases). Mitral valve damage in the form of leaflet tears, chordal rupture and long splits in five cases resulted in significant mitral regurgitation. The leaflet tears resulted in detachment of part of the leaflet from the annulus. A late complication noted was infective endocarditis. Associated pulmonary tuberculosis, chronic obstructive pulmonary disease, respiratory infections and multivalvar diseases also contributed to mortality.

Co-existent renal replacement lipomatosis and pyelitis glandularis

A 50 year old female was found to have a lump on the right side of abdomen with discharging wound on the same side and was ultrasonographically diagnosed as renal cell carcinoma. On histopathology, it showed replacement of the kidney by mature adipose tissue renal replacement lipomatosis, along with pyelitis glandularis which is a rare condition.

Primary malignant carcinoid of the esophagus

Primary malignant esophageal carcinoid in a 55-year-old man with lung abscess is reported. The tumor was detected incidentally at autopsy and had metastasized to the posterior mediastinal lymph nodes.

Isolated left-sided intracardiac fungal mass

A left-sided fungal (Candidial) intracardiac mass was found at autopsy in a 38-day premature infant with hydrops foetalis. Such a manifestation of systemic candidiasis has not been reported previously.

Fibrolamellar carcinoma of the liver--an unusual presentation

Non-bacterial thrombotic endocarditis was found at autopsy in a 17 year old male patient of fibrolamellar type of hepatocellular carcinoma with pericardial metastases. This had resulted in multiple embolic cerebral infarcts with long standing hemiplegia and later death due to acute left ventricular failure.